exam 3 - amenorrhea Flashcards
(26 cards)
A 16 yo girl is brought to you by her worried parents because she has never had a menstrual period… A pregnancy test is negative.
Physical examination of the patient demonstrates Tanner V development… You diagnose the patient with hypothalamic-pituitary-adrenal-ovarian axis immaturity, and recommend she return in 3-6 months if she has not yet menstruated.
amenorrhea definition and etiologies
-No menses by age 15, OR no secondary sex characteristics by age 13
-Occurs in about 2.5% of all patients
-MC etiology- Hypothalamic-pituitary-adrenal-ovarian axis immaturity
-Local etiologies:
-Imperforate hymen
-Vaginal agenesis
-Androgen insensitivity
-Ovarian etiologies:
-Primary ovarian insufficiency due to:
-Iatrogenesis- Chemotherapy, Radiation therapy
-Illness- Viruses (mumps, varicella), Malaria, Tuberculosis, Autoimmune illness
-Genetic etiologies- Turner syndrome, Fragile X syndrome
-Hypogonadotropic hypogonadism- Kallman’s syndrome
-Sheehan’s syndrome- Pituitary dysfunction from surgery or radiation therapy
-Hypothalamic amenorrhea- Anorexia nervosa, Excessive exercise
imperforate hymen
-Vaginal vault present, but introitus not patent
-Treatment: hymenotomy (outpatient)
hematocolpos due to imperforate hymen
vaginal agenesis
-No vaginal vault due to Müllerian anomaly
-May affect cervix, uterus, kidneys
-Occurs in 1:4000-5000
-Type 1 anomaly: absent/hypoplastic uterus, transverse vaginal septum
dx and tx of vaginal agenesis
-Dx: Absent introitus/vault on PE, confirmed by ultrasound
-May show kidney/ureter anomalies
-Tx: Neovagina via dilators or neovaginoplasty if desired
-If ovaries functional, no further tx needed unless hormones needed
androgen insensitivity syndrome complete vs partial
-genotypically 46,XY but is insensitive to endogenous testosterone
-Due to loss-of-function gene in long arm of X chromosome
-Occurs in 1:20,000 liveborn genotypic males worldwide
complete androgen insensitivity:
-No male genitals develop
-Gonads remain in abdominal cavity or in inguinal region
-Female genitalia develop instead- Vagina is usually shorter than normal
-No female upper genital tract organs develop
-Increased risk of testicular CA
-Primary amenorrhea
-Labial swelling/inguinal mass
-Scant axillary/pubic hair
-Tall stature
partial androgen insensitivity syndrome: Genitalia may appear virilized female or undervirilized male
dx and tx and complications of androgen insensitivity syndrome
-Dx: ↑LH, ↑testosterone, ↑serum anti-Müllerian hormone, no uterus on US, 46,XY karyotype
-Tx: Gonadectomy at age 16-18, estrogen replacement, counseling referral, vaginal lengthening as desired
complications:
-Osteoporosis
-Gender identity issues
primary amenorrhea work up flowchart
secondary amenorrhea def, causes
-Amenorrhea after menarche
-Most common diagnosis: pregnancy
others:
-Menopause
-Premature ovarian insufficiency
-Prolactinoma
-Hyperthyroidism
-Post-pill amenorrhea
-Anorexia nervosa
-Medication effects
-Outlet obstruction
-PCOS
signs and sx of menopause or premature ovarian insufficiency and tx
sx:
-Amenorrhea
-Vasomotor sx
-Vaginal atrophy/dyspareunia
-If >45, no need for FSH
-FSH >30 = menopause
tx:
-Menopause: HRT if no contraindications
-Premature ovarian insufficiency: estrogen replacement to prevent osteoporosis, atrophy
prolactinoma overview, dx, tx - micro vs macro
-Benign tumor → amenorrhea, galactorrhea, visual loss due to copression on optic chiasm, infertility, osteoporosis
- may be asymptomatic
Dx: ↑prolactin → MRI brain with contrast
-Hyperprolactinemia: prolactin >25 ng/ml
-Avoid breast stimulation before labs
tx:
Microadenoma: measures <1 cm on MRI
-May be treated with dopamine agonists
-Bromocriptine
-Cabergoline
-Macroadenoma: measures >1 cm on MRI
-Requires resection
-Refer to Neurosurgery
-Refer to ophthalmology or neuro-ophthalmology for formal visual field studies
-Consider contraception in patients who do not desire fertility
hyperthyroidism
-Low TSH → check T4
-High T4 = hyperthyroid
-Low T4 = secondary hypothyroidism
post-pill amenorrhea
-May occur while or after a patient stops using hormonal contraception due to an atrophic endometrium
-The patient has a negative pregnancy test
-Diagnosis is made by relevant history and negative UCG
-Treatment: reassure; no other treatment necessary
anorexia nervosa
-Often causes amenorrhea from low body fat and estrogen
medication effect amenorrhea
-Many medications may cause amenorrhea
-Most are hormones
-Estrogens
-Combined estrogens and progestins
-Testosterone
-Other steroid hormones
-Psychiatric medications may also cause amenorrhea
-Changes in secretion of prolactin
outlet obstruction
-Pts who have had cervical surgery may have scarring of endocervical canal or endometrial cavity, impeding flow of menses
-C/O cyclical crampy abdominal pain, breast tenderness, etc. without vaginal bleeding
-Attempt passage of instrument into uterine cavity (endometrial biopsy catheter, etc.)
-Tx:
-cervical dilation after administration of vaginal misoprostol at home
-May be accomplished in office but is painful
Asherman’s syndrome
- intrauterine adhesions (synechiae) of the uterus form after uterine instrumentation
-Results in diminished menstrual flow or amenorrhea
-MC occurs after uterine instrumentation following pregnancy
-Diagnosis:
-Hysterosalpingography
-Sonohysterography
-Hysteroscopy
-Treatment: hysteroscopic resection of adhesions
PCOS
-4-12% of all patients of reproductive age
-Patients also have insulin resistance and high circulating insulin levels
-Causes both amenorrhea, hyperandrogenism and may cause menometrorrhagia
-Results in hirsutism and obesity
-No ovulation results in a thickened proliferative EM (exposed to estrogen but not to progesterone)
-Eventually, patients will bleed heavily
-Pathophysiology:
-Patients with PCOS often produce relatively more LH than FSH
-Theca cells of ovary produce more androgens than estrogens
-Relatively lower FSH levels make it difficult for androgens to aromatize to estrogen
-Anovulation results
PCOS sx, pe, workup, imaging
-hirsutism (NOT virilization)
-obesity
-acanthosis nigricans
-PE:
-Usually but not always overweight or obese
-Obtain waist circumference (significant if >34”)
-Evaluate on PE for signs of hyperandrogenism
-Acne
-Acanthosis
-Hirsutism
-Dx:
-UCG or bHCG
-Testosterone
-Sex hormone-binding globulin
-TSH
-Prolactin
-FSH/LH
-Random glucose >200 mg/dL, or Hgb A1c
Imaging:
-US of pelvis- At least 12 follicles measuring 2 mm in diameter or increased ovarian volume
-Evaluate endometrial stripe for possible endometrial hyperplasia
-May demonstrate enlarged ovaries with or without the “string of pearls” sign
-≥12 follicles in one or both ovaries
-pic- 13 follicles are seen
-Possible endometrial hyperplasia -EM stripe >1 cm, within normal limits
PCOS diff dx
-Androgen-secreting tumor
-Exogenous androgens
-Cushing’s
-CAH
-Acromegaly
-Hypothalamic amenorrhea
-Turner/ovarian insufficiency
-Thyroid, prolactinoma
PCOS dx criteria
-Rotterdam criteria for diagnosis of PCOS: presence of at least 2 of the following:
-Androgen excess
-Ovulatory dysfunction
-Polycystic ovaries seen on ultrasound
-(dont need to know) NIH criteria: must have both:
-hyperandrogenism
-oligomenorrhea or amenorrhea
long term sequelae of PCOS
-Endometrial CA
-Infertility
-DM
-Hyperlipidemia
management of PCOS
-Protect endometrium with progesterone via:
-Oral contraceptives
-Levonorgestrel IUD
-Cyclic progesterone
-Depot medroxyprogesterone acetate (Depo-Provera)
-Manage DM or insulin resistance/glucose intolerance
-Diet
-Exercise
-As per primary care clinician or endocrinologist
-Treat infertility, if desired
-Folic acid, 400 mcg PO daily (to reduce NTD incidence)
-Ovulation induction
-Achieve spontaneous ovulation, if feasible
-Metformin or rosiglitazone or pioglitazone
-Consider LGP-1 agents
-Manage hirsutism
-May prevent new hair growth with spironolactone or finasteride
-Electrolysis or laser hair removal for existing hair growth
-Manage hyperlipidemia
-Diet
-Exercise
-Possible statin
